The Patient Engagement Challenge

Patient adherence, compliance or engagement. Call it what you want. We must get better at involving the patient in their management.

Countless work goes into finding better ways to solve physical ailments. But what’s the use if the patient isn’t on board?

What’s the point?

Patient engagement applies to those who don’t willingly apply themselves to improve their health. The ones that don’t do their carefully prescribed exercises, for example.

The starting point is finding out why they’re not willing to help themselves.

It’s easy to jump to conclusions and assume that they’re hoping passive treatment will ‘do the trick’. But this is rarely the case. And, even if they do believe that massage will get rid of their pain, their belief points to a lack of understanding rather than stubbornness.

A fundamental part of our role as health professionals is making sure our patients know what their role is. They are the key cog in their recovery. Without them, nothing (good) happens.

The second part is sharing the relevant knowledge – relative to their knowledge gaps – with our patients. What do they need to know to skillfully manage their bodies with confidence?

Filling knowledge gaps

Improving patient engagement

††††††††1. What is their level of engagement?

Once we sense a patient isn’t contributing to their rehabilitation process, we must find out why.

Of course, trust is implicit. Without it, we’re unlikely to find out much more than we already have.

Our questioning should resemble an up-side-down pyramid. First, we must ask broad questions. This helps to set direction and increase comfort. But, quickly, we must hone in and get to the crux of their beliefs.

It takes time to develop these interviewing skills. So, a tool like the Patient Activation Measure (PAM) can help.

Simply put, PAM is a survey that allows us to gauge patient engagement. It uncovers information like a patient’s percevied ability to:

  • Manage their own illness
  • Navigate the health care system
  • Collaborate with health care providers

Although research hasn’t quite determined PAM’s accuracy, it can serve as a guide at the very least.

Example

Physio: Do you feel like you’re responsible for getting back to full health?

Patient: No. I got this injury at work. It’s not my fault. They should fix it.

Above, we can see why a patient might not actively involve themselves in their rehab. Their waiting for others to get them better.

Why is recovery their responsibility if their injury wasn’t their fault?

2. Determine the right approach

We’ve unearthed the problem with incisive questioning (or with help from PAM). The next step is interpreting our (or the survey’s) findings in order to give our patients the tools to succeed.

Example

Physio: Do you feel like you’re responsible for getting back to full health?

Patient: No. I got this injury at work. It’s not my fault. They should fix it.

The problem we face in the scenario above is multi-faceted:

  • First, how good is the patient’s relationship with the workplace? Has the employer admitted that the patient’s injury was their fault? Even this can go along way to removing the feeling of being wronged
  • Second, we must find a way to make the patient realise that, without their contribution, they’re unlikely to get better. We must instil in them that, despite who caused the injury, they’re in the driver’s seat
Locus of control

3. Educate

Our education must centre on the gaps in our patient’s understanding.

If they don’t understand their injury, we must explain it to them.

If they don’t understand their role in managing their injury, we must explain this too.

If they don’t feel like they have the skills to manage their injury, we must teach them the necessary skills (and confidence).

From injury back to health is a journey.

A few patients are like seasoned scouts. They are prepared and well-equipped. They only need a bit of help from us after an injury and they’re back on their way to good health.

But most patients have significant holes in their health management expertise. For these, we must guide them to better health with clear and simple language and strategies. Our education must be tailored. Not only in content but in how we deliver it too.

4. Shared decision making

Do we collaborate with our patient’s or dictate?

A classic example is exercise prescription.

We might have the perfect exercise for our patient. But our patient really struggles with the movement when we practice it in the clinic. We ask, “Are you feeling it here?” and point to their glutes. They shake their head. We shrug and reply, “Never mind, you’ll get it at home.”

We might have the perfect plan. But when our patient comes back a week later, we find that they haven’t done our exercise at all – let alone three times a day like we had set out.

We must work with our patients. It could change our management from being optimal to less optimal. But a less optimal plan that our patients do is better than an optimal one that isn’t done at all.

Physio: Ideally, I’d like you to do this exercise three times a day every day of the week. But what do you think? Can you see yourself doing that?

Patient: Actually, Tuesday’s and Thursday’s are really busy for me. I have to get the kids ready in the morning. Then, there’s work all day. And soccer practice at night. By the time I get home, it’s time for bed.

Physio: I understand. What about doing the exercise five days a week? Is that manageable?

Patient: Yeah – I can do that.

Shared decision making

5. Support outside of the clinic

The time we spend with our patients is a tiny fraction of their week. What if they have questions they forgot to ask? Or, what if their having an issue with an exercise? Normally, their forced to wait until their next visit.

But what if we extended our coverage? What if we kept our communication channels open?

This would surely build trust and improve outcomes.

We could help them with subtle nudges too. “Did you go to hydrotherapy today?” Or, “How is your exercise going?”.

We have to find a balance, of course. And this comes with setting expectations that are fair on the patient and the practitioner.

Touch. Pause. Engage

Touch – Find out where our patient’s are at.

Pause – Get thoughtful. Think of ways we can get them more involved in managing their health.

Engage – Put a plan in place together. Then, act on it.

Even with a plan, getting patient’s engaged can be hard work.

A key takeaway, though, is moving away from the ‘beating our heads against a wall’ model when we find that, week after week, a patient isn’t doing their exercise.

Instead, a scenario like this is a signal to change tact and find out the underpinning reasons why their not helping themselves (rather then giving them a different exercise or berating them like their mother might).

What ways do you influence patient engagement? Do you use any specific tools, like the PAM survey? Leave a comment below.

Author: Andrew Cammarano

Andy writes about anything that comes to mind. Oftentimes, he repeats himself. So, if you read a post and ask yourself, "I feel like I've read this before." Chances are you have. Apart from writing, he eats a diet high in peanut butter, he exercises (and suffers from a chafed butt from performing too many sit-ups in pursuit of a six-pack) and comes up with many fantastical ideas, like his peanut butter-based chafe cream. Reach out to him to share your opinions (or if you'd like to become his chafe cream business partner).

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